HomeMy WebLinkAboutMortgage_Polend� p, STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
.a�_ FOR DEDUCTION FROM ASSESSED VALUATION
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$tate Pofm a3709 (RN / 6-09)
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PresaibeC Dy Depamneni of Local Govemment Finance
❑�uc9G�/LBIIiI�x
Count Township Year
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Fi� M rk
� 7o be (led in person or by maiL Porm filed wim:
Filing Dates: i) Real Property: Muat 6e completed and dated in fhe calendar yea� (or whic6 the deducfion is soughf. U� �, I [� � �
�`� Mus! be filed wil6 fhe Counry Audiror or County Recorder ol fhe caunry where (he property is lowfed LJ County Auditor
on or belore January 5 o7(he immediafely succeeding calendar yeac ❑ County Remrder
�� 2) Mobile /Manu/actured Homes not assessed as Real Property: Must file with the CountyAuditor o/ the-'/ �
.' county where the property is located dunng the tweNe (72) months 6e7ore March 37 o7each year fhe�raa . �
�\�\� deduction is sought.
See reversP side (or additional instmctions and quali(caGons. G IBSON COUNTY AUDITOR
Applicant (owner w convaa buyer - see resUictions an reverse sMe)
Todd M. Polen and Kara D. Polen
jng Disvia Key numbeN legal description Remrd numCer Page num I
iJnion 26-19-08-200-001.842-025 Pi SW NE 8-3-10 rti
Assessed value d real proper^/ as o( Mortgage / Contratt inOeCtedness unpaitl as of Mongage / ConvaU iMebleCness unpaid as ot Is Ihe ao ��n� Ne sde
IAarch 1, wrzenl year March 1, curtent year dale ot application legal or equitable owne/?
5238,900.00 5178,000.00 5179,000.00 ❑� ves ❑ No
II no. wnai is hiz / her e�ad share o( interest? It ovmetl witb someone alher t�an spouse, iMicate with whom
It name on remrE is tliP,erent t�an that ot aOW��n� indicate below. Is the v�operry in vues6on: nnnualy assessed
Q Real Property ❑ MnuallyAssessed
Mobile Home QC 6-1.1-7)
Name ot rtwnga9ee or mnvad selier I
Heritage Federal Credit Union
Adtlress o� mortgagee or wntract seller (number and slreef, ury, sfafe, and ZlP coda) I
5388 Old SR 66, Newburgh, IN 47630
Name of assignee or other owner or holtler ot rtortgage
Address ol assignee (number antl slree�. ciry. s1a:e, antl ZIP code)
Does appliwm oun pwperty in ar.y oNer II yes, what coun,y? what Tacirg D'avict? Has Nis deduction Eeen requestetl rn property I
counry in InCiana? �or curren� yeaR
❑ Yes ❑� No ❑ Yes ❑ No
COUNTY AUDITOR
Deduction apprwetl in I�e amount of: I
20 _ 20 20 _ 20 20 _ 20 20
Sign ture of Counry Audiror Counry Da�e (rsronfh, dag year)
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I/ We certi(y . der ihe penalty of perjury that Ihe above and (oreqoing infortnalion is We and correct and lhat the appliwnt is a resideM of Indiana and
owner / contract buyer of the aforementioned pmperty on date application is filed.
SignaWre (owneYS7u11 name) ��/ Date (rtan1A, tlay, year)
?C� �1 � �1�i. 17- ``�,.� ivz3izoio
FuP resideni address ol apqicant (number arM s:reeL dry, state, and ZIP cotle)
1210 E CR 600 S, Ft Branch, IN 47648
Person authodzed Ey duy eKecvted Po-xer ot Attomey or by IC 6-1.1-12-0] Data (monfh, day, year)
ACaress of auNOrized person (number and sVeeC ciry, 5fate. and ZIP code) �